Updates on Existing Criteria
July 2022. The following changes to criteria are effective July 22, 2022:
Prior Authorization Criteria – Clinical Updates
- Carglumic acid – update required medical information and appropriate treatment regimen for each covered indication
- Empaveli – rename Pegcetacoplan and update reauthorization criteria
- Etelcalcetide – update reauthorization criteria
- Evkeeza and Juxtapid – clarify covered uses
- Fenfluramine – update to include new indication (Lennox-Gastaut Syndrome) and appropriate treatment regimen
- Hormone Supplementation Under 18 Years of Age – update to include transdermal testosterone
- Leuprolide – add Camcevi to affected medications
- Oncology Agents – add Opdualag, Pluvicto, Opdivo and Vonjo to affected medications
- Opdivo – remove stand-alone policy and add to Oncology Agents criteria
- Targeted Immune Modulators – move Avsola to non-preferred products for all covered indications
- Testosterone – rename “Oral Testosterone”, remove topical testosterone products from criteria and add new drug Tlando
Step Therapy Criteria – Clinical Updates
- Antidiabetics – remove policy
- Anti-Herpetic Agents – move acyclovir ointment to step 1
- Insomnia Agents – add Quviviq to step 2 for preferred drug list
Prior Authorization Criteria – Clerical Updates
- Cystadane – rename Betaine
- Elzonris – rename Tagraxofusp-erzs
Preferred Drug List (PDL) Changes
July 2022. The following changes to the drug list are effective July 22, 2022:
Formulary Additions
- Betaine powder add Tier 1 with SP, limited access and prior authorization
- Camcevi prefilled syringe add Tier 3 with SP and prior authorization
- Crinone gel add Tier 3 with medical necessity prior authorization
- Diclofenac potassium capsule add Tier 1 with medical necessity prior authorization
- Lacosamide tablet and solution add Tier 1
- Omnipod 5 G6 pod/intro kit add Tier 2 with quantity limit
- Ozempic solution add Tier 2 with quantity limit and prior authorization
- Quviviq tablet add Tier 3 with quantity limi
- Tlando capsule add Tier 3 with quantity limit and prior authorization
- Triumeq PD soluble tablet add Tier 2 with quantity limit
- Vijoice tablet pak add Tier 3 with SP, quantity limit and prior authorization
- Vonjo capsule add Tier 3 with SP, limited access, quantity limit and prior authorization
Prior Authorization Update
- Add Prior Authorization (Medical Necessity)
- Crinone vaginal gel
- Dxevo 11 day pack
- Remove Prior Authorization
- Androderm patch
- Axiron solution
- Capecitabine tablet
- Testim gel
- Testosterone topical gel/solution
Step Therapy Updates
- Update Step Therapy
- Acyclovir ointment
- Zovirax ointment
- Remove Step Therapy
- Farxiga tablet
- Febuxostat tablet
- Glyxambi tablet
- Janumet tablet
- Janumet XR tablet
- Januvia tablet
- Jardiance tablet
- Metaxalone tablet
- Synjardy tablet
- Synjardy XR tablet
- Trijardy XR tablet
- Uloric tablet
- Xigduo XR tablet
Quantity Limit Updates
- Acyclovir ointment
- Celebrex capsule
- Celecoxib capsule
- Eszopiclone tablet
- Lunesta tablet
- Omnipod DASH kit
- Zovirax ointment
Tier Update
- Combigan 0.2-0.5% solution
- Esgic capsule
- Ketodan foam
- Restasis Emulsion 0.05%
- Restasis MultiDose Emulsion 0.05%
Removed from Formulary
- Capacet capsule
- Lorcet HD tablet
- Lortab tablet
- Lynparza capsule
- Roxicet tablet
See the PacificSource Drug Lists page for the current drug list.
State Based Drug List (OR, ID, MT, WA) Changes
July 2022. The following changes to the drug list are effective July 22, 2022:
Formulary Additions
- Betaine powder add Tier 4 with SP, limited access and prior authorization
- Camcevi prefilled syringe add Tier 4 with SP and prior authorization
- Lacosamide tablet and solution add Tier 1
- Omnipod 5 G6 pod/intro kit add Tier 2 with quantity limit
- Ozempic solution add Tier 2 with quantity limit and prior authorization
- Tlando capsule add Tier 3 with quantity limit and prior authorization
- Triumeq PD soluble tablet add Tier 2 with quantity limit
- Vijoice tablet pak add Tier 4 with SP, quantity limit and prior authorization
- Vonjo capsule add Tier 4 with SP, limited access, quantity limit and prior authorization
Prior Authorization Update
- Add Prior Authorization (Medical Necessity)
- Crinone vaginal gel
- Remove Prior Authorization
- Androderm patch
- Capecitabine tablet
- Testosterone topical gel/solution
Step Therapy Updates
- Update Step Therapy
- Acyclovir ointment
- Remove Step Therapy
- Farxiga tablet
- Febuxostat tablet
- Glyxambi tablet
- Janumet tablet
- Janumet XR tablet
- Januvia tablet
- Jardiance tablet
- Metaxalone tablet
- Synjardy tablet
- Synjardy XR tablet
- Trijardy XR tablet
- Xigduo XR tablet
Quantity Limit Updates
- Acyclovir ointment
- Celecoxib capsule
- Eszopiclone tablet
- Omnipod DASH kit
Removed from Formulary
- Combigan solution; consider brimonidine-timolol 0.2-0.5% solution
- Lynparza capsule; consider Lynparza tablet
- Restasis emulsion and Restasis multidose; consider cyclosporine 0.05% emulsion, Xiidra solution
See the PacificSource Drug Lists page for the current drug list.